Book Review

No Longer Patient: Feminist Ethics and Health Care

Women and Doctors: A Physician's Explosive Account of Women's Medical Treatment -- And Mistreatment -- In America Today and What You Can Do about It

N Engl J Med 1993; 328:360-361February 4, 1993

Article

No Longer Patient: Feminist Ethics and Health Care
By Susan Sherwin. 286 pp. Philadelphia, Temple University Press, 1992. $39.95. ISBN: 0-87722-889-2

Women and Doctors: A Physician's Explosive Account of Women's Medical Treatment -- And Mistreatment -- In America Today and What You Can Do about It
By John M. Smith. 241 pp. New York, Atlantic Monthly Press, 1992. $20.95. ISBN: 1-56023-005-3

These two provocative books look at women, men, and their roles and relations in our health care system. The message in both cases is that the practice of medicine and our thinking about medicine and ethics need revision from a feminist perspective. Stylistically, however, the two accounts differ dramatically, illustrating how the medium can indeed become the message, sometimes in ways that the author never intended.

The title of her book notwithstanding, Susan Sherwin provides a patient, minimally strident, yet fully formed feminist critique of medical ethics and a creative exposition of the improvements possible within a feminist ethics of health care. Her analysis is finely crafted and scholarly, with carefully constructed arguments and thorough references.

In order to make her ideas accessible to a broad audience, Sherwin begins with a concise introduction to feminist theories, addressing many of the objections frequently raised by nonfeminists and differentiating among various feminist visions. Along the way she distinguishes feminist ethics (focused on the general structures of women's oppression in society) from both standard medical ethics (focused on the problems of individual practitioners and policy makers) and “feminine ethics” (focused on approaches to moral reasoning that are more common among or unique to women).

Using all three of these frameworks, Sherwin explores several traditional problems in health care ethics, including abortion and new forms of reproductive technology, before moving on to “expand the bioethics landscape” by examining ascriptions of illness (particularly regarding such entities as premenstrual syndrome and pregnancy), medical constructions of sexuality, and issues of sex, class, and race in the delivery of health care.

Sherwin's analysis echoes a recurring theme: that standard approaches to medical ethics have failed to bring into view the structures in our current health care system that reinforce a sexist oppression of women. Nonetheless, she does not assault individual policy makers and health practitioners for their role in such oppression. Instead, she seeks to educate her readers and to recruit them to join her efforts at reform. The result is an excellent introduction to applied feminism for anyone willing to entertain a fresh perspective on health care ethics.

Education and reform are also John M. Smith's stated objectives, but the tone of his arguments is quite different. His Women and Doctors is written for a lay audience, with the central premise that women are being widely mistreated at the hands of their obstetricians and gynecologists; indeed, he sees sexism and insensitivity to women as so rampant that the only solution may be to eliminate male physicians from the specialty (he does not say how this would be accomplished). Smith is himself board-certified in obstetrics and gynecology, and he makes liberal use of his own collection of anecdotes and horror stories to support his conclusions.

The result is a dramatic, easy-to-read account of the worst of men and the medical profession. The physicians described range from appallingly callous to grossly incompetent, and Smith clearly locates the source of the problem in the attitudes and behavior of individual physicians rather than in institutional structures or socially determined values. Although he acknowledges that most doctors are not “consciously mercenary, dishonest, or hurtful,” he believes they nonetheless dominate and control women as a result of their “underlying prejudice and self-deception.”

Most of the book is devoted to the problem of unnecessary surgery, with Smith observing that three quarters of the women living in America today will have undergone hysterectomy by the age of 65. Smith also criticizes physicians for providing their patients with inadequate information and support; he attempts to remedy this situation in a concluding section that describes various gynecologic conditions and offers guidance to women considering evaluation or treatment.

Thus, while Sherwin's medium is the language of the academy, Smith's is the language of the clinic. Smith's attention to individual responsibility thus complements Sherwin's attention to hierarchical organization at the social and institutional levels.

Unfortunately, Smith's presentation is not that of a gentle, thorough, unbiased clinician. He uses the language not of the clinic he advocates but of the clinic he decries. Whereas Sherwin's tone is measured and conciliatory, Smith's is blunt and confrontational. While she carefully notes context and historical development, he ignores exculpatory motives and speaks in the rhetoric of greed and conspiracy.

This is not to say that Smith imagines the attitudes and behavior he reports. Probably all physicians have seen instances of avarice, incompetence, or indifference in their colleagues (or perhaps even in themselves), and no doubt these problems are exacerbated if a fraternity atmosphere is encouraged in surgical locker rooms. The question is, How extensive is this problem and what should be our response?

Even without firm data on the prevalence of arrogance, aggression, and misogyny among male physicians, eliminating men from the practice of obstetrics and gynecology hardly seems a workable solution., and what would justify our stopping the purge with just one specialty, if these traits were really as pervasive and incorrigible as Smith suggests? As Sherwin notes, “It is dominance and its ties to masculinity that must be eliminated, not the individuals in whom such norms are internalized.”

Nor am I thrilled with Smith's attempts to promote among patients an attitude of defensiveness and distrust:

The health-care system as a whole is actively pursuing you as a patient through the same techniques that everyone with a product is using to get you to be a customer. The danger lies in your failing to understand that. Be a smart, wary consumer, keep the entire health-care system in the same perspective [in which] you probably already have placed car dealers, insurance salesmen, and the makers of food products.

Again Sherwin's direction seems preferable. In her view the health care system should itself be modified, in ways that minimize patients' dependence and professional paternalism, thus ensuring that health services are available within a context worthy of trust.

Creating a trustworthy health care environment over the next few decades may prove to be quite a challenge for any physician -- male or female. The crosscutting message of patient empowerment manifest in these two books should put us on notice -- and offer the hope -- that physicians will not be expected to go it alone.

Kathleen Nolan, M.D., M.S.L.
Mount Tremper, NY 12457